Safety/Sensory
The first action a nurse should take upon assessing a client to ensure client safety
What are two patient identifiers? Ask client's name and date of birth
What is hypoxemia
How to educate a female client to wipe to prevent a UTI
What is wipe front to back?
The type of tissue in a wound that is black/brown in color and is no longer viable
A lab value to assess that may indicate infection
What is WBC?
(White blood cell count, also neutrophils)
6 rights of medication administration
What is... Patient, Drug, Dose, Route, Time, Documentation
Normal ranges for adult vital signs: HR, BP, RR, O2 sat
HR: 60-100 bpm
BP: 90/60 - 120/80 mmHg
RR: 12-20/min
O2 sat: 95% or greater
A nutrient that is necessary for wound healing
What is protein?
A scale that is used to assess risk of pressure injury
What is the Braden Scale?
What is purulent?
Education for a client who is at a fall risk and who voids frequently at night
Ensure good lighting when walking to the bathroom
Use the call light to call for assistance
Also... use non-skid footwear, ensure mobility assistive devices are nearby, use a urinal or other device
The most common modifiable risk factor of chronic obstructive pulmonary disease
What is smoking?
A nursing intervention to prevent infection of an indwelling urinary catheter
What are catheter cares?
perform regularly, typically every 8 hours
3 bony prominences that are at risk for developing pressure sores on a client in a right side lying position
1. Between the knees
2. Right hip
3. Right shoulder, elbow, ankle
When to administer an antibiotic for a client who has a newly diagnosed wound infection and has a wound culture due to be collected.
What is administer the antibiotic after the wound specimen is collected?
A nursing intervention to ensure clear communication to a client who is deaf in their right ear
What is talk into the client's left ear? Stand on left side.
The type of breaths that a client would have when dying
What are cheyne-stokes respirations?
2 priority nursing interventions for a client who, upon assessment, has Lispro insulin due to be given with breakfast and who has a blood sugar of 55.
1. ASSESS level of consciousness, symptoms of hypoglycemia
2. Hold insulin
3. Give client juice and recheck BS in 15 minutes
A priority nursing intervention to relieve pressure from bony prominences to avoid pressure sores
What is reposition the client?
Treatment for inflammatory bowel disease
Anti-inflammatory drugs and antibiotics
Control symptoms - antidiarrheals, pain relievers, vitamins and dietary supplements, rest
Avoid aggravating factors: smoking, stress
A priority nursing intervention when a client is found on the floor and appears to have fallen
What is assess patient's consciousness and/or vital signs. Also assess for noticeable injury.
Do not move the patient. Notify provider. Call for assistance to lift patient. Document appropriately.
What to do when, upon assessment, an extremity has non-palpable pulses, is blue/purple, and is cool to the touch?
What is notify the provider immediately
Priority interventions for when a nurse is inserting an NG tube and the client vomits
Remove NG tube, assess for aspiration, offer antiemetic, attempt to reinsert NG tube
3 mobility concerns for a client who has a history of a right sided stroke with hemiparesis
Assist of 2 with transfers and gait belt
Elevate limp limbs on pillows
Implement fall risk precautions
Three clinical manifestations that a client would present with who has sepsis
What is tachycardia, tachypnea, fever, elevated WBC